Eur J Anaesthesiol 2014; 31:65–67

EDITORIAL

History of anaesthesia: anaesthetics and the Spanish Civil War The start of specialisation Jonathan Browne

European Journal of Anaesthesiology 2014, 31:65–67

During their brief stays in Spain, Macintosh and Boston helped to train Jose Sanchez Galindo, a Spanish military surgeon, in intubation and this practice continued after their departure.

The beginnings of specialisation in anaesthesia during the Spanish Civil War are related to the important role played by Dr (later Sir) Robert Macintosh, who is credited with the first ever recorded use of endotracheal tubes in Spain during his brief visit to the Hospital Militar General Mola in San Sebastian in the autumn of 1937.1

In the Revista Espan˜ola de Medicina y Cirujia de Guerra, No.3 of 1939, an anaesthetic chart dated 14 December 1938 (Fig. 1) records an operation at the Hospital General Mola by Galindo, assisted by Domingo Ledesma Huerta, to carry out a graft from the tibia to the inferior maxilla.4 The intratracheal anaesthetic with ether involved preparation of the nasal passages with a 10% cocaine solution, induction with ethyl chloride, deepening of the anaesthetic with an Ombredanne mask and ether, before proceeding to nasal intubation. This was assisted by the use of a laryngoscope and Rovestine forceps to pass the tube into the trachea, taking advantage of the epiglottis lifting during respiration. This technique was not radically different to current practice. It was, however, to be several years before these techniques began to be used widely in Spain, with patients who benefitted from the protection offered by intubation constituting only a tiny fraction of patients who underwent surgical procedures during this period, and apart from those recorded cases that took place in San Sebastian, there seems to be scant evidence for its use elsewhere.

Macintosh went to Spain at the request of the American plastic surgeon Eastman Sheehan, who had found himself unable to operate on patients with facial injuries due to the fact that the anaesthetic practitioner, a nun, insisted on keeping the mask tightly clamped to the patient’s face. Macintosh, who was forced to improvise, recalled in his diary: ‘When faced with anaesthetising for head and neck surgery in Spain, I was thankful I had seen Flagg’s demonstrations. I cannot think what I would have done without them. I settled for an empty tin of Lyle’s Golden Syrup – a strange find in the circumstances, and well it worked’.2 Although Macintosh did record some of the problems he encountered whilst anaesthetising in Spain, it was his replacement Kenneth Boston from the Radcliffe Infirmary in Oxford who left a more detailed account, recording a total of 33 cases between 10 January and 25 January 1938.3 A thread emerges from these notes of a skilled anaesthetist who nevertheless was seeking to find answers to some of the problems he encountered. These problems included how to deal with deadspace created by keeping the Flagg Tin he was using at a distance from the operating field, frequently marked excitation stages, blockages in the airway and a patient needing re-anaesthetising when an unskilled doctor he was teaching took too long to intubate.

With apparently no nitrous oxide or oxygen, and the Ombredanne Mask the main anaesthesia apparatus, it might seem misleading to talk about the beginnings of specialisation. However, alarmingly high casualty rates (with those killed in action alone amounting to 200 000) meant that in some instances, existing practices were combined with advanced anaesthetic techniques, such as the use of Evipan (hexobarbitone) and ethyl chloride as induction agents, with anaesthesia maintained with ether. Despite its known risks, ether continued to be used in areas exposed to the risk of fire or explosions.

From the School of History, The University of Kent, Canterbury, Kent, UK Correspondence to Jonathan Brown, The School of History, The University of Kent, Canterbury, Kent CT2 7NX, UK Tel: +44 (0)1227 823710; e-mail: [email protected] 0265-0215 ß 2014 Copyright European Society of Anaesthesiology

DOI:10.1097/EJA.0000000000000031

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

66 Browne

Fig. 1

Spain. At the Modern Records Centre at the University of Warwick, as part of the digitalised collection ‘Trabajadores: The Spanish Civil War through the eyes of organised labour’, there is a series of documents relating to the creation of a memorial for Ray Cox, a young man from Southampton who was killed in action in Spain in November 1936.6 In a letter dated 2 April 1937, The Joint Council of the Southampton Trades Council, Labour Party and Co-operative Society, decided to commemorate ‘the Southampton lad . . . killed whilst fighting for the international Brigade’ in Spain by purchasing an anaesthetic machine. The assistant secretary wrote: ‘Further to my letter to you yesterday in regard to the above matter, I have now had a word with our Dr Morgan’ (the Trades Union Congress’s medical advisor) ‘and he thinks that it will be possible to secure quite an effective anaesthetic apparatus for between fifty and sixty pounds. For this figure he is of the opinion that an apparatus can be obtained which would not only be suitable for the administering of ether, but also nitrous oxide’.7 On 8 April, it was decided to go ahead with the purchase of ‘one Boyle’s Nitrous Oxide, Oxygen, Ether Apparatus Hospital set, consisting of a metal stand to take two 200-gallon N2O cylinders and two 60-gallon oxygen cylinders, four fine adjustment valves, sight feed and ether bottles, Facepiece, three way stopcock, bag, tubing and spanner, and an additional bottle for chloroform’.8

An anaesthetic chart 14/12/38.

Evipan and ethyl chloride also proved invaluable due to their short durations of action in the treatment of patients requiring rapid but short surgical interventions.5 General anaesthesia was widely practised where available, but local, regional and spinal anaesthesia were also well established techniques in Spain, with local anaesthesia favoured for head and facial wounds. This was partly not only the result of it being a proven and familiar technique for many surgeons but also because of a lack of facilities for the provision of general anaesthesia beyond the simple mask and ether technique in frontline hospitals. Spinal anaesthesia was the least used technique because many of the patients in frontline hospitals were compromised by shock. There were variations in practice but, due to the lack of reliable data, no accurate statistical analysis can be offered for the frequency of use of any one form of anaesthesia.5 One should also bear in mind that there were numerous occasions when no anaesthetics were available and surgery had to proceed in its absence. Although the birth of modern general anaesthesia in Spain is closely linked with Macintosh, there is evidence of attempts to provide up-to-date general anaesthesia in the hospital of Onteniente, a new 1000-bed hospital with four operating theatres opened in the spring of 1937 in the Republican Zone, prior to the arrival of Macintosh in

After overcoming a few teething problems on where to purchase the apparatus, a letter dated 4 June 1937 recorded that, ‘A nitrous Oxide, Oxygen and Ether Apparatus from Messrs’ Down Bros. Ltd., London had been purchased, with the necessary equipment, cylinders, reserve supplies and a supply of chloroform. The apparatus was now in use in the International Hospital in Onteniente and a plaque affixed stating it was the Ray Cox Memorial’.9 More research is needed to find out if possible for how for long this apparatus was in use and by whom, but this last letter would at least indicate that even though this machine would seem to have been used, albeit briefly, for nonintubated inhalational anaesthesia (there are no references to the purchase of intubation equipment), at least some patients seem to have benefitted from oxygen, and the analgesic properties of intraoperative nitrous oxide, normally referred to as being unobtainable in Spain at the time. An anaesthetic agent that was also of importance during the Spanish Civil War was Evipan, which had been first used in Spain in 1933. With a duration of approximately 15 min of anaesthesia when given intravenously, it was ideal for frontline use in cases of brief duration such as a craniotomy to relieve increased intracranial pressure, but was also a useful induction agent, even if it did not always enjoy widespread popularity due to the fact that there were many surgeons more familiar with other techniques. 5

Eur J Anaesthesiol 2014; 31:65–67 Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

Anaesthetics and the Spanish Civil War 67

Despite the application of techniques new to Spain, anaesthesia during the conflict was still largely dependent on its administration by medical students and nurses. The Swedish/Norwegian Hospital in Alcoi, with modern operating theatres and strict aseptic techniques that even included the use of single-use disposable items, nevertheless had no anaesthetic equipment beyond the usual Ombredanne Mask, with anaesthesia delivered by ‘nurse anaesthetists’, such as the local nurse Amalia Espinos.10

Acknowledgements relating to this article Assistance with the article: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: presented in part at the annual scientific meeting of the European Society of Anaesthesiology, Barcelona, June 2013. Comment from the Editor: this Editorial was checked and accepted by the editors but was not sent for external peer review. Special thanks go to Dr David Wilkinson, who has been organising the EJA series on History of Anaesthesia.

References 1

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The English nurse Penny Phelps’ observation that: ‘I was anaesthetising the wounded with ether or chloroform, then I’d hand the face mask to an orderly while I scrubbed up to assist the surgeon’ reflected the reality in many hospitals.11 Priscilla Scott Ellis, who worked in numerous Insurgent hospitals, recorded in her diary that: ‘A patient came in who had to be amputated above the knee. Ramon operated with . . . me as anaesthetist. I assured them I knew all about it and had done it before, which was a lie’.12 The experiences of these nurses were by no means atypical. Anaesthesia did make some important advances within Spain during the Civil War, and there were moves towards specialisation, but these were highly localised efforts which were to have more of an impact well after the war had ended, with anaesthetic practice during the conflict reflecting more what had gone before rather than what was to come.

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Unzueta Merino MC, Herva´s Puyal C, Villar Landeira J, Robert R. Macintosh and Spain: A Fertile Relationship. Re Esp Anestesiol Reanim 2001; 48:21–28. Wellcome Library and Archives: PP/RRM, Macintosh, Sir Robert (1897–1989), 1937–1989, Collection. Wellcome Library Archives and Manuscripts WLAM: PP/RRM/C/2. Intubation with ether general anaesthesia. Spanish Review of General Anaesthesia 1939; 3:305–316. Franco Grande A, A´lvarez Escudero J, Corte´s Lain˜o J. Historia de la Anestesia en Espan˜a: 1847–1940. Madrid: Ara´n Ediciones; 2005. Trabajadores: the Spanish Civil War through the eyes of organised labour, TUC archives, Modern Records Centre, University of Warwick, Manuscript Series: MSS 292/946/41/24-49. http://contentdm.warwick.ac.uk/cdm/ landingpage/collection/scw. [Accessed 18 November 2013] Tewson, Vincent (Trade Union Congress). Trabajadores: the Spanish Civil War through the eyes of organised labour, TUC archives, Modern Records Centre, University of Warwick, Manuscript Series: MSS 292/946/41/49. http://contentdm.warwick.ac.uk/cdm/landingpa ge/collection/scw. [Accessed 18 November 2013] Tewson, Vincent (Trade Union Congress). Trabajadores: the Spanish Civil War through the eyes of organised labour, TUC archives, Modern Records Centre, University of Warwick, Manuscript Series: MSS 292/946/41/41. http://contentdm.warwick.ac.uk/cdm/landingpage/collection/scw. [Accessed 18 November 2013] Minutes of the Joint Council of Southampton Trades Council, Labour Party and Co-operative Society, 4. June 1937. Trabajadores: the Spanish Civil War through the eyes of organised labour, TUC archives, Modern Records Centre, University of Warwick, Manuscript Series; MSS 292/946/39/103. http://contentdm.warwick.ac.uk/cdm/landingpage/collection/scw. [Accessed 18 November 2013] Beneito Lloris A. The Swedish/Norwegian Hospital of Alcoi during the Spanish Civil War. Visual Producciones; 2004; pp. 58–61. Palfreeman L. Salud! British Volunteers in the Republican Medical Service during the Spanish Civil War, 1936-1939. Eastbourne: Sussex Academic Press; 2012; pp. 119. Scott-Ellis P. The chances of death: a diary of the Spanish civil war. Carr R, editor. Norwich: Michael Russell (Publishing) Limited; 1995 !

Induction of anaesthesia with a separate agent appears to have been a practice that came into more common use during the conflict, especially in relation to Evipan. In Salamanca, a young Moroccan patient being prepared for surgery in March 1938 asked not to be given the ‘water that makes you stupid’ (ether, which is alcohol-based), and, in deference to his wishes and his religious sensibilities, the doctor induced the patient with Evipan before then giving ether to maintain anaesthesia, a technique also favoured by Boston.3

Eur J Anaesthesiol 2014; 31:65–67 Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

History of anaesthesia: anaesthetics and the Spanish Civil War: The start of specialisation.

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